Globally, World Health Orgnisation (WHO) has been pushing for universal health coverage with a goal of ensuring that all people obtain the health services they need without suffering financial hardship. It was a policy adopted to ensure continued progress towards the current health Millennium Development Goals by 2030by various state signatories.
Whereas that’s the case, many Ugandans still find themselves spending a significant amount of their income on health, which in most cases leaves many languishing in poverty notwisthstanding the government’s frequentridiculous notions of free health care provisionat public health facilities. Health is a fundamental human right whose realization requires the active participation of the various stakeholders.
At the beginning of the 21st century, the government of Uganda began implementing a series of health sector reforms that were aimed at improving the poor health indicators prevailing at the time. Among the reforms was the health financing policy since funds from the mainstream government, donors and private sector were inadequate to provide good quality health care expected by the citizens. Health insurance was proposed as alternative source to augment financing of health care.
Ministry of Health (MoH) initiated a plan to develop a national social health scheme. The purpose of the scheme was intended to diversify and strengthen health care financing and make a contribution to bridging the financing gap in the sector; to stimulate providers to avail good quality, accessible and affordable healthcare. The development of the National Social Health Insurance Scheme (NSHIS) was hinged on the World Health Organisation (WHO) resolution, Uganda’s Constitution of 1995, the National Health Policy (1999-2009), the Health Sector Strategic Plan I, II and III and the National Development Plan (2010/11-2014/15).
The 1995 Constitution emphasised that the state should take all practical measures to ensure the provision of basic medical services to the population. In 1996, Uganda’s MoH commissioned the first feasibility study on health insurance, and some limited Community Health Insurance (CHI) pilot schemes were attempted. The feasibility study was exploratory and looked at the potential for establishing social health insurance in Uganda.
The goal of the National Health Policy (NHP) was to ensure attainment of a good standard of health by all Ugandans and to promote a healthy and productive life in an equitable manner. Ministry of health was enlisted to explore alternative, equitable and sustainable options for health financing and health service organization targeting the poor and other vulnerable groups.
The Health Sector Strategic Plan I (2000/1-2004/5), II (2005/6-2009/10) and III (2010/11–14/15) highlighted development of alternative health financing mechanisms among which was Social health insurance (SHI). A second feasibility study undertaken in 2001 recommended that Uganda pursues a strategy of starting up SHI gradually, by initially covering only civil servants and their families located in large cities plus workers and their families employed by large companies. The study recommended that step-by-step, the scheme could be expanded to include all workers and their families in the formal sector, and hopefully the informal sector as well.
In 2006, the Government of Uganda asked the MoH to design a health insurance scheme through a cabinet minute No. 63 (CT 2006). The Minister of Health established a national task force on health insurance, with representation from all relevant stakeholders such as MoH, Ministry of Finance, Ministry of labor and gender, Ministry of public service, trade Unions and Federation of Uganda employers to spearhead drafting of the Bill and design issues. The purpose of the Bill was to diversify and strengthen health care financing, stimulate providers to provide good quality services at affordable prices and increase welfare gain in health care through financial risk protection. It was hoped that the introduction of a national health insurance scheme would lead the government to embark on improved health infrastructure, human and financial resources and availability of basic goods and services as a holistic revamping of the provision of health care in Uganda. However the scheme faced stiff criticism from major stakeholders, who described it as another burden to employees, expressing fears that such a policy might increase the already high cost of doing business in the country.
Later on in 2011, government directed the Minister of Health to issue additional principles of the bill to the First Parliamentary Council taking into consideration stakeholder concerns through cabinet minute 84 (CT 2011). Also the National development plan provided for the establishment of health-financing mechanisms (NHI and other community health-financing mechanisms) based on prepayment and financial risk pooling with the goal of achieving universal coverage and social health protection
In 2012, the cabinet approved National Health Insurance Bill to be tabled in parliament. But surprisingly it wasn’t passed into law. The bill was composed of three sub-schemes, including social health insurance, community-based health insurance (CBHI) largely comprising of the informal sector, and private-commercial health insurance, which would be implemented concurrently.
With the recent improvements in 2019, cabinet approved the National Health Insurance Scheme (NHIS) that required all Ugandans above 18 years to contribute to the scheme before accessing health services across the country. The bill also intended to facilitate the provision of accessible, affordable acceptable and quality healthcare services to citizens irrespective of their age, economic, health and social status.
Every contributor upon payment of the prescribed contribution, would be issued with a card for purposes of identification and verification. Employees in the formal sector would be subjected to 4% deductions from their salaries while their employers would contribute 1% to while individuals in the informal sector would pay a proposed Shs100,000 annually and pensioners contribute 1% of their monthly pension payment. For every contributor, a spouse and children below 18 years would access the defined benefits packages irrespective of the amount of contribution and should both wife and husband be working in the formal sector, both would have to pay for the health insurance scheme.
However, underprivileged people such as the poor who hardly earned $1.5 (about Shs5,462) a day, people with disability, the elderly, orphans, street children and people above 18 years with no formal or informal employment would not pay any fee, but would get insurance cards from the government to access health services. Individuals without an insurance card would not access health services but immunization since free medication in all hospitals would be phased out, once the Bill was enacted. Individuals with emergencies, including those involved in accidents, would be able to access free services even without the health insurance card.
The National Social health insurance scheme is commendable and if streamlined to the current needs in the sector, will go far in respect to the realisation of the right to health for all Ugandans as stipulated in international, regional and national legal/policy frameworks. However, there are some challenges and constraints that need to be adressed if the bill is going to address the practical realities of our traditional family set up and the underlying health problems.
In Uganda, the working legal definition of a child is anyone below the age of 18. The people that stand to benefit largely from this scheme are mainly rural based, poor and unemployed who normally live in extended family setups with many children and young adults from dead relatives or others unable to take care of their own. This is a reality in Uganda and families don’t normally go through the intricate legal process of adoption. Therefore, this clause as is proposed automatically excludes many children who are under mere guardianship or foster care placement. There is need to harmonize with the extended family set up without necessarily opening up more case load for the judiciary in adoption applications which are in themselves not practical under temporal foster care and guardianship, which is a norm in traditional society Uganda.
Enrolment is legally mandatory but non-compliance is an obstacle that faces this scheme if implemented, as it is a social policy that is difficult to enforce, given the large informal sector for which there is no database and the need for formal sector workers to voluntarily pay a registration fee to be enrolled. This is solely due to the fact that employers are not comfortable paying NSSF, PAYE and other deductions.
In addition, emerging evidence reveals a variety of implementation problems such as the perceived poor quality of health care, delays that may arise out of NSHIS card production and distribution, lack of trust in scheme management, long waiting times for insured clients and high enrolment dropout rates.
The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the four phases of development: from 1995 to 1999; 2000 to 2005; 2006 to 2011 and 2012- 2019. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Ministry of Health following a directive from the President, withdrew the National Health Insurance Bill in 2020. The country has been waiting for this scheme for more than 10 years. The ministry has spent 20 years designing it. Of the three East African countries; Kenya, Tanzania and Rwanda, only Uganda is without National Social Health Insurance Scheme. It should be noted, that the law alone, no matter how sound it is, cannot effect meaningful transformation without the political will to address the challenges that affect the realisation of the right to universal health care.
Peter Kabuye is a student of Dental Surgery at Uganda Christian University.
@peterkabuye on Twitter.